A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following is the BEST indicator of true labor that the nurse should recognize?

Premature rupture of the membranes.

Light irregular pattern of contractions.

3 station of the presenting part.

Progressive cervical dilation.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Premature rupture of the membranes refers to the breaking of the amniotic sac before labor starts. It is not a definitive indicator of true labor, as contractions and cervical changes need to accompany it to confirm labor onset.

Choice B rationale

Light irregular pattern of contractions is often associated with false labor or Braxton Hicks contractions. True labor contractions are typically regular, progressively stronger, and closer together.

Choice C rationale

3 station of the presenting part refers to the baby's descent into the pelvis. While it indicates labor progression, it is not the most definitive sign of true labor compared to cervical changes.

Choice D rationale

Progressive cervical dilation is the most reliable indicator of true labor. It signifies that the cervix is opening up in response to regular and effective contractions, indicating the body is preparing for childbirth.

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Correct Answer is B

Explanation

Choice A rationale

Increased fetal movement is normal and usually not a sign to head to the hospital unless there are other concerns.

Choice B rationale

Ruptured membranes can signify the beginning of labor or risk for infection, warranting a visit to the hospital for assessment.

Choice C rationale

Contractions that are 10 minutes apart typically indicate early labor, but not necessarily the need to go to the hospital immediately.

Choice D rationale

Mild abdominal or groin discomfort can occur during pregnancy and does not immediately warrant a hospital visit without other signs of labor.

A. Take pressure off of the presenting part of the fetal head. B. Prepare the client for an immediate cesarean birth. C. Place the client in a knee-chest position. D. Attempt to gently put the cord back inside.

Correct Answer is D

Explanation

Choice A rationale

Taking pressure off of the presenting part of the fetal head can help improve blood flow and oxygen supply to the fetus, potentially preventing hypoxia.

Choice B rationale

Preparing the client for an immediate cesarean birth is a necessary step in cases of umbilical cord prolapse to quickly deliver the baby and reduce the risk of fetal distress.

Choice C rationale

Placing the client in a knee-chest position helps to alleviate pressure on the umbilical cord, increasing blood flow and oxygen supply to the fetus.

Choice D rationale

Attempting to gently put the cord back inside is not recommended as it can cause more harm and increase the risk of cord compression and infection.

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A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not.”. Which of the following is the BEST indicator of true labor that the nurse should recognize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital.The nurse's teaching was effective when the patient states that she will come when she:

Correct Answer is B

Explanation

A nurse is caring for a client who is in the first stage of labor.The nurse observes the umbilical cord protruding from the vagina.Which of the following actions should the nurse NOT perform?

Correct Answer is D

Explanation

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